Dr Balmer believes this failure to make the fundamental changes that PBC could bring is largely because of a heavy-handed managerial approach.

‘PCTs are generally recognising that they have been too slow, have cut bureaucracy and are getting better at taking risks, but by their nature are very risk averse. I think this stems from the SHA – it is very controlling,' he says.

But Dr Balmer also believes GPs must shoulder some of the blame for the lack of advances.

He says: ‘In some of our PCTs our commissioning groups are too small. If you don't act with one voice on the big issues you'll never get anything done. We've not made that jump from that local cohesion to letting go and being able to speak with one voice to the PCT.

‘The small commissioning groups have been acting like provider groups – setting up dermatology services, things like that. There has been some success in that, but it has been grindingly slow.'